Apply to become a FUSIC® Heart Mentor

Your details

Name ^* (required)

Job title/grade ^* (required)

Hospital/Trust address ^* (required)

Email ^* (required)

Which of the following ultrasound qualifications have you held for at least the past 12 months? ^* (required)

FUSIC Heart

BSE Level 1

BSE Level 2 TTE (or equivalent)

FEEL

Other

If you answered 'other', please provide us with more information.

What date did you complete your qualification? ^* (required)

How many years have you been practicing ultrasound? ^* (required)

Please give a brief summary of your training and level of expertise in ultrasound in the critically ill: ^* (required)

Supervisor details

Name ^* (required)

Job title ^* (required)

Hospital address ^* (required)

Phone number ^* (required)

Email address ^* (required)

Which of the following ultrasound qualifications has your supervisor held for at least the past 12 months? ^* (required)

FUSIC HD

EDEC

BSE Level 2 TTE (or equivalent)

Cardiologist with regular TTE commitment

Other

If you answered 'other', please provide us with more information

How many years have they been practicing ultrasound? ^* (required)

Please provide any supporting documentation if appropriate

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Become a FUSIC® Heart Mentor